Alert ACA SECTION 1202 Payment
| To: | HPSJ Providers (Excluding Federally Qualified Health Clinics (FQHC) and Rural Health Clinics (RHCs) |
| From: | Health Plan of San Joaquin – Provider Services Department |
| Subject: | ACA SECTION 1202 Payment |
Pursuant to the Affordable Care Act (ACA) as amended by the H.R. 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, ACA and 42 Code of Federal Regulations (CFR) 447, state Medicaid agencies are required to reimburse primary care physicians with a specialty designation of family medicine, general internal medicine or pediatric medicine for specified Evaluation and Management (E&M) and Vaccine Administration services.
NOTE: Providers needed to submit the an ACA Self Attestation Form (SAF) with their individual NPIs by December 31, 2014 in order to receive supplemental payments for service dates between January 1, 2013, through December 31, 2014.
Frequently Asked Questions
Ongoing Payment Requirements
Q: What can I do to ensure I am receiving the enhanced payment owed to me?
You can do several things to ensure you are receiving the enhanced payment owed to you:
- If you are a FFS Physician directly contracted with HPSJ, make sure you are submitting your claims with your individual NPI as the rendering Physician. Claims with a Group NPI are not eligible for the enhanced payment.
- If you are capitated, make sure you are submitting all of your encounters and that the encounters have your individual NPI as the rendering Physician. Encounter records with a Group NPI are not eligible for the enhanced payment.
- If payments for eligible providers are made to a medical group or clinic, the medical group or clinic must sign and submit the HPSJ medical group/clinic attestation form to Health Plan of San Joaquin. If you are a Medical Group and do not have a copy of the form, please contact HPSJ’s Provider Services Department at (209) 942-6340.
Before HPSJ can issue any payment, providers must have: (1) submitted the state-required self-attestation; (2) completed/sent the HPSJ medical group/clinic attestation form to HPSJ (if applicable); and (3) submitted timely and accurate encounter data if receiving capitated reimbursement.
Q: Why have I not received a payment?
Payments were made in June and November 2014 to all providers who met the criteria for payment. Please confirm that you have met the above criteria. If you think you have met the above criteria, and you still have not received payment, please contact HPSJ’s Provider Services Department at (209) 942-6340.
Q: I did not meet all of the criteria for the previous payments. If I submit the required information, when can I receive my payment?
HPSJ will continue to process any claims and encounter records with dates of services January 1, 2013 through 2014 for all providers who met the requirements described above. To ensure that we capture all of your claims and encounters, we encourage you to have all of these claims submitted by no later than April 30, 2015.
Q: How will HPSJ calculate the enhanced payment?
The enhanced payment will increase Medi-Cal reimbursement for services to the lesser of billed charges or the ACA Medicare fee schedule. DHCS has published an ACA Medicare fee schedule for office site of service with geographic adjustments. HPSJ will be utilizing this ACA Medicare fee schedule to calculate the enhanced payments.
Q: DHCS posted the ACA Local Code to CPT Crosswalk on the DHCS Medi-Cal website in April 2014, so some ACA-eligible claims using local codes had been submitted without ACA modifiers. Will HPSJ pay the enhancement retroactively for these claims?
Yes, HPSJ will reprocess eligible claims, retroactive to January 1, 2013, to make these enhanced payments.
Eligible Providers should submit to HPSJ the “NICU/PICU Claim To ACA Modifier Assignment Spreadsheet template,” which can be found on the DHCS Medi-Cal website under the Downloads Section of this page: http://files.medi-cal.ca.gov/pubsdoco/aca/aca_form_landing.asp –
- HPSJ requires Providers to include an additional column with the HPSJ claim number.
- HPSJ set up a secure site for these submissions. Please contact HPSJ’s Provider Services Department at (209) 942-6340 to obtain site information, username, and password.
Q: What if I did not receive the correct enhanced payment?
Please make sure you have reviewed your eligible encounter submissions through the Provider Portal (DRE) at http://providers.hpsj.com/ to reconcile against your records before contacting HPSJ. If you find a discrepancy, please gather the following information before calling as this information is required for HPSJ to research any incorrect payment:
- Physician Name
- Individual Physician NPI
- Physician TIN
- Member name
- HPSJ Member ID
- Date of Service
- Reason (i.e., not included in payment, underpaid)
If you believe, after your review, that you have received the incorrect enhanced payment amount, please contact HPSJ’s Provider Services Department at (209) 942-6340. We will review and advise you on next steps.
Q: When will HPSJ make another payment?
HPSJ will make another payment by March 31, 2015 for eligible claims with dates of service in CY2013.
Q: I have received a check without RA (Remittance Advice) what do I do?
You will receive an encrypted CD following the disbursement of the check. If you do not receive the CD within 5 business days of receipt of your check, please contact the Provider Services Department at (209) 942-6340.
Details on the Affordable Care Act (ACA) Section 1202 Supplemental Payment, can be found in the Provider Payment Section of the HPSJ on-line Provider Manual at http://providers.hpsj.com/provider-tools-resources/.
The Provider Manual can also be accessed through our HPSJ website portal Doctor’s Referral Express (DRE).
The ACA 1202 Supplemental Payments provide enhanced reimbursement to help you partner with us to expand access to quality, cost-effective health care for our members. If you have any questions, please contact the Provider Services Department at (209) 942-6340.